application Office Use Only
SEPTIC DISPOSAL PERMIT APPLICATION Permit#: 5ef 255- ��
Permit Fee:$ 1(5- ; Invoice#: 140-0
To ofcZ���sury Septic Variance? Yes No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
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TOWN OF QI EENSBURY
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Applicant L DING& CODES 1
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Name(s): tips., , --ia y-. .f/ -74 :-.:$ L-LC
Mailing Address, C/S/Z: 30 /2l-e , ,5—c C�++"lc,, ,11 K /ZReo'71
Cell Phone: _(5"i ) Z 3'Z--L'7c"7 . Land Line: _( '5)8 ) "'ri?/—/i) 41-8
• Primary Owner(s)
Name(s): F) I — �--v 5 -- 0 kda d
Mailing Address, C/S/Z: / � .'i i. Q3 P1 , C e;c - 6 ,.',-NI ,Al.? JZ c-,j/
Cell Phone: _(5 ) $q —c'/ /z- Land Line: ( )
Email:
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted pith this application
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Contact Name(s): -- -tee J �- i -- S L ...0 I pp
prt Gs r-.a. 1 t'1 3� Ga.k a 3;3a'0.'i�� ��lc-
Contractor Trade: <5 .c p f--8 c� -I e ..6
Mailing Address, C/S/Z: LTc'c , '.i c - 0 4,5;l'e<4.1oc c ,; .41,,,P f' I '
Cell Phone:_(�% ) ; Z-E 7 Land Line: _( / S , J c,.
Email: ti c1=�., - el-t I ,.,_x-.1 .:J:s/ - ; e. C9 4:-f...
• Engineer(s):
Name(s): 4 i /4 z
Mailing Address, C/S/ : ,JFj,6 ,3A Aac/e- r, (57 5
Cell Phone: _(5/j ) yeF- 7177 Land Line: _( )
Email:
Contact Person for Building & Code Compliance: �'`'^ io�-' c' C-,
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Cell Phone: Vie ) Z- 67' 7 Land Line: _,(57 ) & 4/4 ICD 7443
Email: et-eo. s,-2 , 4" .-z t r ,�el L°,:y--- -:^-i ° , cm e)1,-, ,.
Septic Application Revised February 2019
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes 407
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 110 / /Lo
PARCEL INFORMATION:
Topography X Flat Rolling Steep Slope %Slope
Soil Nature y Sand _Loam _Clay _Other(explain: )
Groundwater At what depth? /"i me, 4-0h 7Z i e
-
Bedrock/Impervious material At what depth? �f 44. -e, 7z s''
Domestic Water Supply _Munici al Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION: --- ‘" •
Tank size ffir0 gallons(min.size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub t)ei
System Absorption field w ' si€ Total length / 2 ft.; Each Trench .j ft. �J,, ..
Seepage Pit with#3 stone How many: ;Size:
Alternative System Bed or other type:
Holding Tank System Total required capacity? ;tank size ;#of tanks
NOTES: 1. Alarm system and associated electrical work must be inspected by a Town approved electrical inspection
agency; 2. We will no longer allow systems to be covered until such time as an as-built plan is received and
approved. The installed system must match the septic layout on file—no exceptions. 3. As-built drawings must be
submitted prior to the inspection, if there has been a change to the submitted plans.
Declaration: Any permit or approval granted which is based upon or is granted in reliance upon any material
representation or failure to make a material fact or circumstance known by or on behalf of an applicant, shall be
void. I have read the regulations and agree to abide by these and all requirements of the Town of Queensbury
Sanitary Sewage Disposal Ordinance.
PRINT NAME: !a' k,; IVY" /C i DATE: ,PZ —„,j
SIGNATURE: ' /---
DATE:
Septic Application Revised February 2019